Loading...
HomeMy WebLinkAboutMO-9541_40974_CA_UST-61_20180327_24-Hour Release and UST Leak Reporting FormlST=G'1 24-Hou0" Release and UST For Releases This form should be completed and submitted to the UST Section's regional office fallowing a known or suspected release from an underground storage tank (UST) system. This farm is required to be submitted within 24 hours of discovery of a known or in NC suspected release (DWM USE ONLY) Suspected Contamination? (Y/N) ___ __ Facility ID Number _ Incident # Risk (H,I,L,U) _ Confirmed GW Contamination? (Y/N) ___jj Date Leak Discovered _y/�%lV Received On _ _ Received By ______ Confirrnod Soil Contamination ?(Y/N) __ t Con'o - ercia __/____'__ Reported by (circle one): Phone, Fax or Ropon Samples Taken?(Y/N) __� Rog on -regulated ________ - Region Free Product? (YIN) N___ If Yes, State Greatest Thickness INCIDENT DESCRIPTION Incident Name: ^ II • \eSr \�,�,.n [T Address: 3 S Zo C'� Q t' County: � ;kn �QLO City/Town: L\ , I Zip Code: O Rogional Office (circle one): Asheville, res I ayetleville, Raleigh, Washington, Wilmington, Winston-Salem Latitude (dedmaldegl a ): ^�' 1'�/ `Q" QLongitudo (neo�„��,i„�y„«a U�r '"`� d Obtained by: Briefly describe suspected or confirmed release: (including but not fimited to: nature of release, date of release, amount ❑ GPS of release, amount of free product present and recovery efforts, initial responses conducted, impacts to race tors ❑ Topographic map \AK^ \,<�\ ( �\`,� `\` y i ;\` �1 a�A _ �\ �� _ ❑ GIS Address matching ❑ Other ❑ Unknown Describe location: csasSl..M �� c + ! \ ( Iz.43 �� Q GR) .� •.hs HOW RE EASE WAS DISCOV RED (Release Code) (Check one) ❑ Release Detection Equipment or Methods U Visual/Odor Cl Groundwater Contamination ❑ During UST Closure/Removal U Water ,n Tank ❑ Surface Water Contamination ❑ Property Transfer ❑ Water Supply Well Contamination Other (specify) SOURCE OF CONTAMINATION Source of Release Cause of Release Type of Release Product Type Released (Chock one to indicate primary (Check one to indicate primaty (Chock one) (Check one to indicate primary product type source) cause) released) 'T� Tank ❑ Spill � Petrcleum ❑ Gasoline/ Diesell ❑ DieselNeg. Oil "� Kerosene Blend ❑ 7[L. ❑ Piping Overfill U Non-Pelroloum Hosting Oil ❑ Vegetable Oil 100% ❑ Dispenser ❑ Corrosion U Both ❑ Other Petroleum ❑ E10 - E20 ❑ Submersible Turbine Pump ❑ Physical or Mechanical Products ❑ E21 - E84 Cl Damage Location Motals ❑ Delivery Problem ❑ E85 - E99 ❑ Install Problem (Chock one) ❑ Other Inorganics ❑ Other ❑ Other Organics ❑ Ethanol 100% r l ❑ Other Facility ❑ Unknown � ❑ E01 - E09 iy y Unknown Residence Definitions presented on reverse Definitions presented on rovers& ❑ Other Ownership 1. Municipal 2. Military 3. Unknown Private 5. Federal 6. County 7. Slate Type -\ 1. Publicc Service 2. Agricultural 3- esltlentia 4. EducatioNRelig. 5. industrial 6. Commercial 1. Mining 1. Public UST Form 61 (02/08) C�Ge�c�e0 IMPACT ON DRINKING WATER SUPPLIES Water Supply Wells Affected? 1. Yes 2. No rUn own Number of Water Supply Wells Affected ___-------- ____ Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet it necessary) 1. 2. 3. UST SYSTEM OWNER UST Owner/Company Point of Contact Address City State Zip Code Telephone Number UST SYSTEM OPERATOR UST OperatorlCompany Addross City late Zip Code Telephone Number LANDOWNER AT LOCATION OF UST INCIDENT Landowner t Li Ad dress 1013 8�x City State Zip Code Telephone Num,per V\Ao" N ' ,r 2'70310 My WP Draw Sketch of Area (showing two major road intersections) or Attach Map f?1c +moo to fiJi < ,7 3-� 10 [Peraon Reporting Incident Company p \ Telephone Number Cyr S� Vr—� Address l. Data 717 UST Form 61 (02108) Ch a��6\(C. _ Papa 2 of 2 Definitions of Sources 2�l` Tank: means the tank that stores the product and is pan of the underground storage tank system Piping: means the piping and connectors running front the tank or submersible turbine pump to the dispenser or other end -use equipment ( Vent, vapor recovery, or fill lines are excluded.) Dispenser includes the dispenser and the equipment used to connect the dispenser hi the piping (e.g., a release from a suction pump or from components located above the shear valve) Submersible Turbine Pump (STP) Area includes the submersible turbine pump head (typically located in the lank sump), the line leak detector, and the piping that connects the submersible turbine pump to the tank Delivery Problem: identifies releases that occurred during product delivery to the lank. (Typienl causer associated with this source are Npilis and uvcrrillx l Other: serves as the option to use when the release source is known but dues not tit into one of the preceding categories (e.g., for releases from vent lines, vapor recovery lines, and fill lines) Unknown: identifies releases for which the source has not been detennincd Definitions of Causes Spill: use this cause when a spill occurs (e.g., when die delivery hose is diseomicded tram the lank fill pipe or when the nuzzle is removed from the dispenser) Overfill: use when an overfill occurs (e.g., overfills may occur from the fill pipe at the tank or when the nozzle fails to shut off at the dispenser) Physical or Mechanical Damage. use for all types of physical or mechanical damage, except corrosion (e.g., puncture of tank or piping, loose finings, broken components, and components that have changed dimension) Corrosion: use when a metal tank, piping, or other component has a release due to corrosion (e.g., for steel, corrosion takes the form of rust) Installation Problem: use when the problem is detennined it) have occurred slwcifically because the UST system was not installed properly Other: use this option when the cause is known but does not fit into one of the preceding categories (e.g., putting regulated substances into monitoring wells) Unknown: use when the cause has not been deterniined PO Box 681016 Charlotte, NC 28216 Phone: 877-505-6799 Fax: 704-56-1173 www,cert-Lisa.com Underground Storage Tank Inspection 3520 Draper Ave., Charlotte, NC 3/9/18 Residence 3520 Draper Ave. Charlotte, NC Subject: Home Heating Oil Underground Storage Tank (UST) Inspection The inspection of an underground storage tank (UST), at the above address was completed on 2/26/18. Facing the house from the street, the tank is located under the house (in the living room area), accessed through a crawl space door, located in the rear of the house. It is 7 feet off the structure into the crawl space. The tank appears to be a 550 gallon home heating oil tank. It is 5 '/2 feet to the bottom of the tank from the land surface. The tank was found to be empty. One soil boring was taken on the side of the tank from inside the house (see photo). The field soil sample was taken from a depth of 7 feet. The field test result, with the Photoionization Detector (PID), was 140 PPM (Parts Per Million) Volatile Organic Content (VOC). The field test result appears to be above the Division of Waste Management, UST Section, North Carolina Department of Environmental Quality action level of 50 PPM for GRO and 100 PPM for DRO (gasoline and diesel). This indicates that soil contamination is present at the sample location. Additionally, a soil sample was taken to the laboratory for analysis. CERT instructed the laboratory to analyze the soil sample for Total Petroleum Hydrocarbons (TPH) by EPA GRO/DRO Method. The NCDEQ requires sample preparation Method GRO when analyzing for low to medium boiling point fuels which include gasoline and gasohol. Sample preparation method DRO is required when analyzing for high boiling point fuels such as jet fuels, home heating oil, kerosene, fuel oil #2 and diesel. The laboratory findings are reported as parts per million (PPM) TPH. TABLE 1 LABORATORY RESULTS TPH GRO/DRO PID (VOC) PPM PPM Sample # 1 91.6/6530 140 Analytical results for soil sample: Field analysis indicated that the sample location was suspect with regards to petroleum contamination. The laboratory analysis confirmed that the soil was impacted under the underground storage tank. The soil sample was analyzed for EPA GRO/DRO. The GRO/DRO results were above the Minimum Quantification Limits (PPM) Total Petroleum Hydrocarbons. The Division of Waste Management, UST Section, North Carolina Department of Environmental Quality action levels are 50 PPM for GRO and 100 PPM for DRO (gasoline and diesel). Laboratory results confirm that contaminated soil is present under the tank location. It is recommended that the tank owner submit a 24-Hour Release and UST Leak Reporting Form (UST-61) be sent to NCDEQ as required by State regulation (CERT can assist with this form). The environmental activities, described above, in no way represent a complete environmental assessment, only determining that contaminated soil is present at the sample location described above. This process has been initiated at the request of the UST representative. Please retain this report for your records. Regards, Stephen M. Hamilton Consultant SMH/jh 2 % e-11t$4 i S. o . Technical Report for Spectrum Environmental Residence; 3520 Draper Ave, Charlotte, NC SGS Job Number: FA52119 Sampling Date: 02/26/18 Report to: Spectrum Nationwide PO Box 790541 Charlotte, NC 28206 smhamilton@comporium.net ATTN: Steve Hamilton Total number of pages in report: i. .S� I`ccR�O . 3 E Test results contained within this data package meet the requirements Caitlin Brice, M.S. of the National Environmental Laboratory Accreditation Program General Manager and/or state specific certification programs as applicable. Client Service contact: Muna Mohammed 407-425-6700 Certifications: FL(E83510), LA(03051), KS(E-10327), IL(200063), NC(573), NJ(FL002), NY(12022), SC(96038001) DoD ELAP(ANAB L2229), AZ(AZ0806), CA(2937), TX(T104704404), PA(68-03573), VA(460177), AK, AR, IA, KY, MA, MS, ND, NH, NV, OK, OR, UT, WA, WV This report shall not be reproduced, except in its entirety, without the written approval of SGS. Test results relate only to samples analyzed. SGS North America Inc. 4405 Vineland Road Suite C-15 Orlando, FL 32811 tel: 407-425-6700 fax: 407-425-0707 Sections: Table Section 1: Sample Summary................................................................................................... 3 Wd Section 2. Summary of flits .. .. ... .... ... . 4 x°E w ... ........ —......... .a..,,�,a., 3 _1 FA52119-1: SAMPLE 1............................................................................................... 6 Section4; Misc. Forms............................................................................................................ 8 4.1: Chain of Custody........................................................................................................... 9 Section 5, t1t" Volatiles - QC I)ata Sunimaries................................,a..>.>,...... .............m..a.. 11 5.1: Method Blank Summary................................................................................................ 12 52: Blank Spike Summary................................................................................................... 13 5<: Matrix Spike/Matrix Spike Duplicate Summary........................................................... 14 S,4,,C cpn 6" " /l.tsenli volatiles - ; l t,.. sumniaria ",—.....A„..........>.a.......... 15 6,1. Method Blank Summary................................................................................................ 16 6, : Blank Spike Summary................................................................................................... 17 63 Matrix Spike/Matrix Spike Duplicate Summary........................................................... 18 2 y 1.6' SGS North America Inc. Sample Summary Spectrum Environmental Job No: FA52119 Residence; 3520 Draper Ave, Charlotte, NC Sample Collected Matrix Client Number Date Time By Received Code Type Sample ID FA52119-1 02/26/18 11:00 SH 03/01/18 SO Soil SAMPLE 1 Soil samples reported on a dry weight basis unless otherwise indicated on result page. 3ofI.E. Summary of Hits Page 1 of 1 Job Number: FA52119 Account: Spectrum Environmental Project: Residence; 3520 Draper Ave, Charlotte, NC Collected: 02/26/18 Lab Sample ID Client Sample ID Result/ Analyte Qual RL MDL Units Method FA52119-1 SAMPLE 1 TPH-GRO (C6-C10) 91.6 56 28 mg/kg SW846 8015C TPH (C10-C28) 6530 1200 590 mg/kg SW846 8015C Of 3 "?I1a Report of Analysis 5 of 18 SGS North America Inc. Report of Analysis Client Sample ID: SAMPLE 1 Lab Sample ID: FA52119-1 Date Sampled: 02/26/18 Matrix: SO - Soil Date Received: 03/01/18 Method: SW846 8015C Percent Solids: 83.9 Project: Residence; 3520 Draper Ave, Charlotte, NC Page Iof1 File ID DF Analyzed By Prep Date Prep Batch Analytical Batch Run #1 CD149569.D 1 03/05/18 16:35 EG n/a n/a GCD6250 Run #2 Initial Weight Final Volume Methanol Aliquot Run #1 6.49 g 5.0 ml 10.0 ul Run #2 CAS No. Compound TPH-GRO (C6-C10) CAS No. Surrogate Recoveries 460-00-4 4-Bromofluorobenzene 98-08-8 aaa-Trifluorotoluene Result RL MDL Units Q 91.6 56 28 mg/kg Run# 1 Run# 2 Limits 86% 56-149% 72% 66-132% ND = Not detected MDL = Method Detection Limit j = Indicates an estimated value RL = Reporting Limit B = Indicates analyte found in associated method blank E = Indicates value exceeds calibration range N = Indicates presumptive evidence of a compound 6 of 18 �A52,,a SGS North America Inc. Report of Analysis Client Sample ID: SAMPLE 1 Lab Sample ID: FA52119-1 Date Sampled: 02/26/18 Matrix: SO -Soil Date Received: 03/01/18 Method: SW846 8015C SW846 3546 Percent Solids: 83.9 Project: Residence; 3520 Draper Ave, Charlotte, NC Page 1 of 1 File ID DF Analyzed By Prep Date Prep Batch Analytical Batch Run #1 WW15096.D 200 03/09/18 00:25 NJ 03/08/18 12:20 OP69061 GWW610 Run #2 Initial Weight Final Volume Run #1 20.1 g 1.0 ml Run #2 CAS No. Compound TPH (C10-C28) CAS No. Surrogate Recoveries 84-15-1 o-Terphenyl (a) Outside control limits due to dilution. Result RL MDL Units Q 6530 1200 590 mg/kg Run# 1 Run# 2 Limits 0% a 56-122% ND = Not detected MDL = Method Detection Limit J = Indicates an estimated value RL = Reporting Limit B = Indicates analyte found in associated method blank E = Indicates value exceeds calibration range N = Indicates presumptive evidence of a compound Misc. Forms Custody Documents and Other Forms Includes the following where applicable: • Chain of Custody J -1,,..,-`.`i Accutest Laboratories Southeast � •�� Chain of Custody FA5211q �ACCUTEST 4405Vineland Road, Suite C-15 Orlando,Fl32811 ACCUtB5tJ08# PAGE l OF I LABORATORIES TEL. 407-425-6700 • FAX: 407-425-0707 www.accutest.com cCuteSt Cluole Client I Reporting nformation Project Information Analydcal Information I Matnx Codes Com any Name G - PrpjW Name: \ C ,(2� ` DW - aNldng Weter GWWW-Netter sw. - surtece water L- ud+ 9L -.011Sludge a•al Lro - aher Liquid AIR -Air �aWoe01d IMF ONLY Address S Sue tfeel �C O `l J c t, state L Z1 Stela a Y I'Mad Contacts +nail R.I.0 9 PfpneN .1-" L lNarne le)(Ptlnte� FazB $emPlerls \ y-M r Vet CI urchase Orft9 Acatan sa N Field ID / Point of Collection sAvPLEn unrnu TOTAL or € 1 -US f 5 tr TURNAROUND TIME Business Days) Data Deliverable Ourmanion Cornmenls/Remarks ❑ 10 Days Standard Approved By: I Rush Code ❑ 7 Day RUSH 5 Day RUSH -- _— 3 Day EMERGENCY ❑ 2 Day EMERGENCY _ ❑ t Day EMERGENCY _ ❑ OTHER Emergency o Rush T/A Data Available VIA Email or Lablink /CQ � COMMERCIAL "A" (RESULTS ONLY) COMMEqRCpIALL"B" (RESULTACI OUTC i T REDT1 Ili 2&0 QUEEN C t T Y DR FULTi IEPA LEVEGL T NC �EDD'S\V 4 Ale SannoIa Custodvt be documenteAbelow each m' i:Iudino courier delive ReI 'sh by r: 1 ate Time: a1Z g 2 By: by : 3 Dai itme: 27 %y✓G Received By: 4 A 1N Relinquishe 5 a q'Time: C !� B R ived B : �P Relinquished 7` ate Tme: Recel By p B b Lab Use Only'. Cust Seal in Place: Y IN Temp Blank Provided: Y IN Preserved where Applicable: Y N Total # of Coolers: Cooer Temperatures Isius: , 0 of z SGS Sample Receipt Summary Job Number: FA52119 Client: CERT Project: RESIDENCE Date / Time Received: 3/1/2018 1:45:00 PM Delivery Method: FED EX Airbill #'s: 1015906964210003281100808776151445 Therm ID: IR 1; Therm CF: 0.4; #of Coolers: 1 Cooler Temps (Raw Measured) °C: Cooler 1: (3.6); Cooler Temps (Corrected) °C: Cooler 1: (4.0); Cooler Information Y or N Sample Information Y or N N/A 1. Custody Seals Present W ❑ 1. Sample labels present on bottles V ❑ 2. Custody Seals Intact V ❑ 2. Samples preserved properly d❑ ❑ 3. Temp criteria achieved ❑o ❑ 3. Sufficient volume/containers recvd for analysis: d❑ ❑ 4. Cooler temp verification IR Gun 4. Condition of sample Intac 5. Cooler media Ice(Bag) 5. Sample recvd within HT ❑d ❑ 6. Dates/Times/IDs on COC match Sample Label Q ❑ Trio Blank Information Y or N N/A 7. VOCs have headspace ❑ ❑ ❑,i 1. Trip Blank present / cooler ❑ ❑ ❑d 8. Bottles received for unspecified tests ❑ ❑J 2. Trip Blank listed on COC ❑ ❑ ❑d 9. Compositing instructions clear ❑ ❑ ❑d W or S N/A 10. Voa Soil Kits/Jars received past 48hrs? ❑ ❑ ❑d 11. % Solids Jar received? ❑J ❑ ❑ 3. Type Of TB Received ❑ ❑ d❑ 12. Residual Chlorine Present? ❑ ❑ W Misc. Information Number of Encores: 25-Gram 5-Gram Number of 5035 Field Kits: 1 Number of Lab Filtered Metals: Test Strip Lot #s: pH 0-3 230315 pH 10-12 219813A Other: (Specify) Residual Chlorine Test Strip Lot #: ;omments SOIL IS MATRIX. NOT ON COC. shoot Rev. Date 0524/17 Technician: SHAYLAP Date: 3/1/2018 1:45:00 PM Reviewer: P.H Date: 3/1/2018 ]"A521 19., of Custody of 18 Section 5 GC Volatiles QC Data Summaries Includes the following where applicable: • Method Blank Summaries • Blank Spike Summaries • Matrix Spike and Duplicate Summaries Method Blank Summary Job Number: FA52119 Account: SPECNCC Spectrum Environmental Project: Residence; 3520 Draper Ave, Charlotte, NC Page 1 of 1 Sample File ID DF Analyzed By Prep Date Prep Batch Analytical Batch GCD6250-MB CD149567.1) 1 03/05/18 EG n/a n/a GCD6250 The QC reported here applies to the following samples: FA52119-1 CAS No. Compound Result RL TPH-GRO (C6-C10) ND 5.0 Method: SW846 8015C MDL Units Q 2.5 mg/kg CAS No. Surrogate Recoveries Limits 460-00-4 4-Bromofluorobenzene 88% 56-149% 98-08-8 aaa-Trifluorotoluene 74% 66-132% 2-of' A521 a Blank Spike Summary Job Number: FA52119 Account: SPECNCC Spectrum Environmental Project: Residence; 3520 Draper Ave, Charlotte, NC Page 1 of 1 Sample File ID DF Analyzed By Prep Date Prep Batch Analytical Batch GCD6250-BS CD149566.1) 1 03/05/18 EG n/a n/a GCD6250 The QC reported here applies to the following samples: FA52119-1 CAS No. Compound TPH-GRO (C6-C10) CAS No. Surrogate Recoveries 460-00-4 4-Bromofluorobenzene 98-08-8 aaa-Trifluorotoluene * = Outside of Control Limits. Spike BSP BSP mg/kg mg/kg % Limits 20 22.0 110 74-128 BSP Limits 88% 56-149% 88% 66-132% Method: SW846 8015C Y,. Matrix Spike/Matrix Spike Duplicate Summary Page 1 of 1 Job Number: FA52119 Account: SPECNCC Spectrum Environmental Project: Residence; 3520 Draper Ave, Charlotte, NC Sample File ID DF Analyzed By Prep Date Prep Batch Analytical Batch FA52180-1MS CD149573.1) 1 03/05/18 EG n/a n/a GCD6250 FA52180-1MSD CD149574.1) 1 03/05/18 EG n/a n/a GCD6250 FA52180-1 CD149568.1) 1 03/05/18 EG n/a n/a GCD6250 The QC reported here applies to the following samples: Method: SW846 8015C FA52119-1 FA52180-1 Spike MS MS Spike MSD MSD Limits CAS No. Compound mg/kg Q mg/kg mg/kg % mg/kg mg/kg % RPD Rec/RPD TPH-GRO (C6-C10) 7.3 U 29.2 33.6 115 29.2 33.5 115 0 74-128/17 CAS No. Surrogate Recoveries MS MSD FA52180-1 Limits 460-00-4 4-Bromofluorobenzene 92% 94% 86% 56-149% 98-08-8 aaa-Trifluorotoluene 91% 89% 74% 66-132% * = Outside of Control Limits. QC Data Summaries Includes the following where applicable: • Method Blank Summaries • Blank Spike Summaries • Matrix Spike and Duplicate Summaries 5of1 Method Blank Summary Job Number: FA52119 Account: SPECNCC Spectrum Environmental Project: Residence; 3520 Draper Ave, Charlotte, NC Page 1 of 1 Sample File ID DF Analyzed By Prep Date Prep Batch Analytical Batch OP69061-MB WW15095.D 1 03/08/18 NJ 03/08/18 OP69061 GWW610 The QC reported here applies to the following samples: Method: SW846 8015C FA52119-1 CAS No. Compound TPH (C10-C28) CAS No. Surrogate Recoveries 84-15-1 o-Terphenyl Result RL MDL Units Q ND 5.0 2.5 mg/kg Limits 73% 56-122% Blank Spike Summary Job Number: FA52119 Account: SPECNCC Spectrum Environmental Project: Residence; 3520 Draper Ave, Charlotte, NC Page 1 of 1 Sample File ID DF Analyzed By Prep Date Prep Batch Analytical Batch OP69061-BS WW15094.D 1 03/08/18 NJ 03/08/18 OP69061 GWW610 The QC reported here applies to the following samples: FA52119-1 CAS No. Compound TPH (C10-C28) CAS No. Surrogate Recoveries 84-15-1 o-Terphenyl * = Outside of Control Limits. Spike BSP BSP mg/kg mg/kg % Limits 50 43.3 87 62-116 BSP Limits 82% 56-122% Method: SW846 8015C P 't ' of Matrix Spike/Matrix Spike Duplicate Summary Page 1 of 1 Job Number: FA52119 Account: SPECNCC Spectrum Environmental Project: Residence; 3520 Draper Ave, Charlotte, NC Sample File ID DF Analyzed By Prep Date Prep Batch Analytical Batch OP69061-MS WW15100.D 1 03/09/18 NJ 03/08/18 OP69061 GWW610 OP69061-MSD WW15101.D 1 03/09/18 NJ 03/08/18 OP69061 GWW610 FA52180-1 WW15099.D 1 03/09/18 NJ 03/08/18 OP69061 GWW610 The QC reported here applies to the following samples: Method: SW846 8015C FA52119-1 FA52180-1 Spike MS MS Spike MSD MSD Limits CAS No. Compound mg/kg Q mg/kg mg/kg % mg/kg mg/kg % RPD Rec/RPD TPH (C10-C28) 6.0 U 60.4 48.3 80 60.1 46.3 77 4 62-116/35 CAS No. Surrogate Recoveries MS MSD FA52180-1 Limits 84-15-1 o-Terphenyl 79% 77% 78% 56-122% * = Outside of Control Limits. 8 of 13 241 our Release and UST r For Releases This form should be completed and submitted to the UST Section's regional office following a known or suspected release from an underground storage tank (UST) system. This form is required to be submitted within 24 hours of discovery of a known or in NC suspected release (DWM USE ONLY) Suspected Contamination? (YIN) __`j _ __ Facility 10 Number Incident # Risk (H,I,L,U) _ Confirmed GW Contamination? (Y/N) � Date Leak Discovered Received On ___ Received By _----- Confirmod Soil Contamination ?(Y/N) __ r__ Co o - ercia . ________ Reported by (circJe one): Phone, Fax or Report Samples Taken?(Y/N) __�_ Rog on -regulated _------- ___ Region Free Product? (YIN) If Yes, State Greatest Thickness INCIDENT DESCRIPTION Incident Name: T •��' Address: �CU V County: TgNxz'- � City/Town: , ¢ Zip Code: O L©� Regional Office (circle one): Asheville, ores 'Ile ayetleville, Raleigh, Washington, Wilmington. Winston-Salem Latitude (dacJmold.gr ): QLongitudo (nnce„n i„e ,«. yG, r '� r' Obtained by: ❑ GPS Briefly describe suspected or confirmed release: (including but not limiled to: nature of rolease, date of release, amount of release, amount of free product present and recovery ofloris, initial responses conducted, impacts to receptors) ❑ Topographic map ❑ GIs Address matching ❑ Other ❑ Unknown Describe location: d. ; ;\` k� d�a �\ �� J 1 c;. r.Z u.�r.� s. ��C.. S c� 2 Q v+ -'X-3 `:i Q Qr 5 3�3 41U HOW REfEASE WAS DISCOV RED (Release code) (Chock one) ❑ Release Detection Equipment or Methods ❑ Visual/Odor ❑ Groundwater Contamination ❑ During UST Closure/Removal ❑ Water in Tank ❑ Surface Water Contamination ❑ Property Transfer ❑ Water Supply Well Contamination Other (specify) � 1_ O C 1 1% SOURCE OF CONTAMINATION Source of Release Cause of Release Type of Release Product Type Released (Check one to indicate primary (Check one to indicate pnrnary (Chock one) (Check one to indicate primary product type source) cause) released) Tank ❑ Spill Petroleum ❑ Gasoline/ Diesel/ ❑ DieselNeg. Oil Kerosene Blend ❑ Piping ❑ Overfill ❑ Non -Petroleum Heating Oil ❑ Vegetable Oil 100% ❑ Dispenser ❑ Corrosion ❑ Both ❑V Other Petroleum ❑ E 10 — E20 ❑ Submersible Turbine Pump ❑ Physical or Mechanical Products ❑ E21—E84 ❑ Damage Location Metals ❑ Delivery Problem (Check one) ❑ Other Inorganics ❑ E85 — E99 ❑Install Problem ❑ Other ❑ Other Organics ❑ Ethanol 100% ❑ Other Facility ❑ Unknown ❑ E01 — E09 Unknown Residence Definitions presented on reverse I Definitions presented on reverse ❑ Other Ownership 1. Municipal 2. Military 3. Unknown Private 5. Federal 6. County 7. State Operatlon Type 1. Public Service 2. Agricultural 3..esidential 4. Education/Relig. 5. Industrial 6. Commercial 7. Mining UST Form 61 (02/08) rye i m RECEIVE® APR 0 4 2018 NC®EQ SIR® UST IMPACT ON DRINKING WATER SUPPLIES Water Supply Wells Affected? 1. Yes 2. No ' own Number of Water Supply Wells Affected ___�—------- ,___ Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary) 1. 2. 3. UST SYSTEM OWNER UST Owner/Company Point of Contact Address City State Zip Code Telephone Number UST SYSTEM OPERATOR UST Operator/Company Address City tale Zip Code Telephone Number LANDOWNER AT LOCATION OF UST INCIDENT Landowner hA 0,e'rt\ Address 100 &OL 60 City ', State Zip Code 2,7030 Telephone Number I 37a 17-9.96l0 r Draw Sketch of Area (showing two major road intersections) or Attach Map f44t— v 104"1'31 i,' Person Reporting Incident Company \ Telephone Number Title ��� Address IDale 7 UST Form 61 (02/08) ' Page 2 of 2 Definitions of Sources Tank: means the tank that stores the product and is part of the underground storage tank system Piping: means the piping and connectors running from the tank or submersible turbine pump to the dispenser or other end -use equipment (Vent, vapor recovery, or fill lines are excluded.) Dispenser includes the dispenser and the equipment used to connect the dispenser to the piping (e.g., a release from a suction pump or from components located above the shear valve) Submersible Turbine Pump (STP) Area includes the suhmeraihle turbine pump head (typically located in the tank sump), the line leak detector, and the piping that connects the submersible turbine pump to the tank Delivery Problem: identifies releases that occurred during product delivery to the tank. (Typical causes associated with thin snuree arc spills and overfills.) Other: serves as the option to use when the release source is known but does not ail into one of the preceding categories (c.g., for releases from vent lines, vapor recovery lines, and fill lines) Unknown: identifies releases for which the source has not been detennined Definitions of Causes Spill: use this cause when a spill occur (e,g., when We delivery hose is disconnected from the tank Jill pipe or when the nuzzle is removed from the dispenser) Overfill: use when an overfill occurs (e.g., overfills may occur from the till pipe at the tank or when the nozzle fails to shut off at the dispenser) Physical or Mechanical Damage: use for all types of physical or mechanical damage, except corrosion (e.g., puncture of tank or piping, loose firings, broken components, and components that have changed dimension) Corrosion: use when a metal tank, piping, or other component has a release due to corrosion (e.g., for steel, corrosion takes the form of rust) Installation Problem: use when the problem is determined to have uccumd s1wcifictdly twcause the LIST system was not installed properly Other: use this option when the cause is known but dues not fit into une of the preceding categories (e.g., putting regulated substances into monitoring we)ls) Unknown: use when the cause has not been detennined